TITLE 41

INSURANCE

CHAPTER 18

THE INSURANCE CONTRACT

41-1854 [41-1855].  health care — cash price for services. [Effective January 1, 2027] (1) As used in this section, the terms "covered person," "health benefit plan," "health care provider," "health care services," "health carrier," and "medically necessary" shall have the same meanings as provided in section 41-5903, Idaho Code.

(2)  A health carrier may not prohibit a health care provider from offering a covered person the option of paying the provider’s discounted cash price for health care services. For the purposes of this subsection, "discounted cash price" means the charge that applies to a covered person who pays cash for a health care service. With respect to a hospital, the discounted cash price shall have the same meaning as provided in 45 CFR 180.20 if the hospital has a discounted cash price. It does not mean the amount charged to individuals who are eligible for free care or are eligible for the amounts charged pursuant to a hospital’s financial assistance policy.

(3)  A covered person may choose to pay out of pocket for a health care service from a health care provider.

(4)  If a covered person obtains a medically necessary health care service covered by such person’s health benefit plan and negotiates for a price lower than the allowed amount established by the benefit plan, as provided to the covered person upon request, and the covered person pays out of pocket for the health care service, the amount of the out-of-pocket cost shall be counted toward the covered person’s out-of-pocket deductible and annual maximum out-of-pocket expense if the requirements of this section are met.

(5)  A health carrier that receives the documentation described in subsection (6) of this section shall count the full amount that the covered person paid out of pocket toward the deductible and annual maximum out-of-pocket expense if:

(a)  The health care service is covered under the health benefit plan of the covered person; and

(b)  The covered person negotiated for a lower cost for the health care service than the allowed amount established by the covered person’s health benefit plan for that covered health care service.

(6)  A covered person shall electronically send documentation to the health carrier that provides the following information:

(a)  The health care services the covered person or patient received and the name of the health care provider and contact information;

(b)  The final bill or statement for the health care services; and

(c)  The negotiated cost of the health care service that the covered person received and documentation that:

(i)   The covered person paid out of pocket for the health care services received; and

(ii)  The health care provider is not making a claim against the health carrier for payment of the health care service provided to the covered person or patient.

(7)  The health care provider shall accept the discounted cash payment from the covered person as payment in full and shall not bill the covered person or the health carrier for any balance between the amount collected from the covered person and the billed charge for the service by the provider.

(8)  The amount of the out-of-pocket cost shall be attributed to the in-network deductible and annual maximum out-of-pocket expense if the provider was an in-network provider and to the out-of-network deductible and annual maximum out-of-pocket expense if the provider was an out-of-network provider.

(9)  The amount counted toward an applicable out-of-pocket deductible and annual maximum out-of-pocket expense shall not exceed the total amount that the covered person is required to pay out of pocket during a contractually agreed on period of time for health care services that are included under the health benefit plan of the covered person and shall not carry over once a new contract or agreement period for the plan begins.

(10) The provisions of subsections (4) through (9) of this section shall not apply to:

(a)  A plan that provides coverage:

(i)   Only for a specified disease or diseases;

(ii)  Only for accidental death or dismemberment;

(iii) Only for dental or vision care;

(iv)  Under an individual limited benefit policy;

(v)   For a hospital confinement indemnity policy;

(vi)  For disability income insurance or a combination of accident-only and disability income insurance; or

(vii) As a supplement to liability insurance;

(b)  Any programs administered by the Idaho department of health and welfare through the state medicaid program under title XIX of the federal social security act, as amended;

(c)  A medicare supplemental policy as defined by section 1882(g)(1) of the social security act;

(d)  Worker’s compensation insurance coverage;

(e)  Medical payment insurance issued as part of a motor vehicle insurance policy;

(f)  A long-term care policy, including a nursing home fixed indemnity policy, unless a determination is made that the policy provides benefit coverage so comprehensive that the policy meets the definition of a health benefit plan; or

(g)  Short-term health insurance issued on a nonrenewable basis with a duration of six (6) months or less.

(11)  Nothing in this section shall be construed to waive or override prior authorization, medical necessity, or utilization management requirements under the health benefit plan.

History:

[(41-1855) 41-1854, added 2026, ch. 275, sec. 1, p. 1161.]